Why did VA employees manipulate wait time data, resulting in thousands of Veterans lingering on wait lists for care and at least 23 veterans dying because they had to wait too long?

Phillip Longman, author of the Best Care Anywhere: Why VA Health Care Is Better Than Yours—which, I’ve argued elsewhere, is partially responsible for the scandal—blames it on veterans migrating to states in the “Sun Belt” area. `The Sun Belt is roughly the strip of states running from Nevada and Southern California all they way over to Florida and then up into South and North Carolina. Longman claims so many veterans moved to these areas in recent years that the VA facilities there were overwhelmed, leading to long wait times.

In my latest National Policy Analysis, “Veterans Will Suffer Another Scandal As Long As Bureaucracy Runs Their Health Care,” I find the evidence does not support the Sun Belt theory. The VA’s recent audit of the scandal listed 81 facilities needing “further review ” (see pages 38-40). Of those 41 are in the Sun Belt, while the other 40 are not. A review of Government Accountability Office and VA Office of the Inspector General reports that examine wait times shows a similar pattern. Examining reports from 2000-2014 that contained wait-time data on specific locales reveals 21 in the Sun Belt and 22 located elsewhere.

Clearly, this is not a scandal limited to a specific geographic location. Rather, the explanation is to be found in the incentives and constraints that a bureaucracy like the VA faces. Here’s one:

[One] problem with bureaucracies is they don’t get their funding from the people who are seeking their services. In the private sector, those people are generally called “customers,” although in the healthcare sector they are usually referred to as “patients.” If customers have to wait too long to receive a service from “Business A,” they will take their money to businesses that offer shorter wait times. Business A will see its revenues decline and either have to shape up or go under. Like most bureaucracies, the VA has no such “feedback loop,” since the people seeking their services aren’t the same ones paying for it. In short, there is no financial consequence for poor customer service.